COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : : Plaintiff(s) -against- Calendar No. JUDICIAL SUBPOENA : : : Defendant(s) : ...................................................... IN THE SUPERIOR COURT OF WASHINGTON THE PEOPLE OF THE STATE OF FOR THE COUNTY OF KING NEW YORK In TOthe Guardianship of: ) ) ) ________________________ ) GREETINGS: An Incapacitated Person ) ___________________________________ ) Case No. INITIAL PERSONAL CARE PLAN (PCP) WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court I. ASSESSMENT located at that apply in each category: County of Check all in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence 2. a witness in this actionTRANSPORTATION: as PRIMARY MEANS OF on the part of the 1. HOUSING COMPOSITION: ___ Lives Alone ___ Own Car ___ Lives with Spouse ___ Public ___ Lives with Children ___ Transportation Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to ___ Lives with Relative ___ Friend / Relative the ___ Lives with Non-Relative subpoena was issued for a maximum penalty of $50 and all damages sustained as a party on whose behalf this ___ Other: _____________________ result of Other: ____________________ ___ your failure to comply. 4. IF LIVES IN HOME – SERVICES NEEDED: 3. LIVING ARRANGEMENT: ___ None Witness, Honorable , one of the Justices of the ___ Home Owner ___ Chore Services (household chores) Court in County, day of , 20 ___ Renter ___ Other : _____________________ ___ Adult Family Home _____________________ ___ Cong. Care Facility _____________________ ___ Nursing Home (Attorney must sign above and type name below) ___ Senior Housing 6. PROSTHETIC DEVICES ___ Other: ____________________ ___ None ___ Walker/Cane Attorney(s) for 5. FUNCTIONAL LIMITATION: ___ Wheelchair ___ Speech ___ Hearing Aid ___ Hearing ___ Artificial Limb ___ Vision ___ Dentures ___ Walking Office and P.O. Address INITIAL PERSONAL CARE PLAN - Page 1 of 5 2001 Guardianship Forms Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Plaintiff(s) Calendar No. : JUDICIAL SUBPOENA 7. NEEDS ASSISTANCE FOR: 8. NEEDS ASSISTANCE TO LEAVE HOME: -against: ___ Yes ___ Eating ___ Essential Shopping with IP ___ Toileting ___ Essential Shopping for IP ___ No : ___ Ambulation ___ Meal Preparation ___ Transfer ___ Laundry: : ___ Positioning ___ Facilities in Home ___ Personal Hygiene ___ Facilities out of Defendant(s) : .Home . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... ___ Dressing ___ Housework ___ Bathing ___ Self Medication ___ Travel to Medical Service THE PEOPLE OF THE STATE OF NEW YORK Comments: TO ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ __________________ GREETINGS: ______________________________________________________________________________________ ______ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend ______________________________________________________________________________________ before ______ , the Honorable at the Court located at County of Circle one of the following codes for each item listed below: , at in room , on the day of , 20 o'clock in the noon, and at any recessed Y=Yes; N=No; CD=Cannot Determine. Y N CD or adjourned date, to testify and give evidence as a witness in this action on the part of the 9. INCAPACITATED PERSON’S ABILITY TO HANDLE EMERGENCIES: Knows what to do in the event of a fire. Y N CD Knows what to do in case of medical emergency (doctor, ambulance). Y N CD Knows what to do in the event of this subpoena is punishable as a contempt of courtY will make you liable to a break-in or robbery. N CD Your failure to comply with and Knows how to call emergency telephone servicesfor a maximum penalty of $50 andY damages sustained as a (911). N CD the party on whose behalf this subpoena was issued all 10. INCAPACITATED PERSON KNOWS HOW TO SEEK HELP FROM OTHERS TO result of your failure to comply. KEEP SUPPLY OF GOODS AND OBTAIN SERVICES (HOUSEKEEPER, LAWYER, COMMUNITY SERVICES). Y N CD Witness, Honorable , one of the Justices of the 11. INCAPACITATED PERSON’S FINANCIAL ABILITIES: Court in County, day of , 20 Able to collect benefit, retirement, social security, V.A. benefits. Y N CD Able to maintain checking accounts with balance greater that $___________ Y N CD Able to pay monthly bills for rent, utilities, etc. Y N CD Willing and able to spend money for necessary goods and services, i.e. food, Y N CD (Attorney must sign above and type name below) clothing, sundries, etc. Able to seek help in money management. Y N CD Able to manage funds. Y N CD Attorney(s) for List sources of income and/or resources to pay for monthly costs and care: ________________________________________________________________________________________ ______ ________________________________________________________________________________________ Office and P.O. Address ______ ________________________________________________________________________________________ ______ INITIAL PERSONAL CARE PLAN - Page 2 of 5 2001 Guardianship Forms Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. ________________________________________________________________________________________ : ______ JUDICIAL SUBPOENA Plaintiff(s) -against- Estimated monthly costs and care: Housing: $ _____________ Food: $ _____________ : Other: : _____________________ _ : Utilities: $ _____________ _____________________ _ Defendant(s) : .Clothing and Laundry: . . . . . $ . . . . . . . . . . . . . . . . . . . . . _____________________ ................ . _____________ .......... _ Medical: $ _____________ _____________________ _ Recreational: $ _____________ _____________________ THE PEOPLE OF THE STATE OF NEW YORK _ Insurance: $ _____________ _____________________ TO _ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ 12. INCAPACITATED PERSON’S PSYCHOLOGICAL / SOCIAL / COGNITIVE FUNCTIONING: GREETINGS: Y N CD Y=Yes; N=No; CD=Cannot Determine. DISORIENTATION: WE COMMAND YOU, that allor time: and excuses being laid aside, you andY each of you attend before Able to relate to person, place business N CD , the Honorable IMPAIRMENT: at the Court MEMORY Y N CD located within the hour: County of Can remember events occurringat Can remember events day of within the,day: occurring Y in room , on the 20 , at o'clock in the noon, N at any recessed and CD Can remember eventsgive evidence asthewitness in this action on the part of the occurring within a week: Y N CD or adjourned date, to testify and IMPAIRED JUDGMENT: Able to make appropriate decisions, solve problems, and respond to major life Y N CD changes: COMMUNICATIONS: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to CD the party on Able to understand what is being said: whose behalf this subpoena was issued for a maximum penalty of $50 andY damages sustained as a all N Able to express thoughts and needs: Y N CD result of your failure to comply. WANDERING: Moves about aimlessly, or in pursuit of an unobtainable goal: Y N CD Witness, ABUSIVE , one of the Justices of the VERBALLY HonorableBEHAVIOR: Court in , 20 Threatens /County, others,day ofuses foul language, etc.: berates yells, Y N CD DISRUPTIVE OR INAPPROPRIATE BEHAVIOR: Makes excessive demands for attention, takes another’s possessions, disrobes Y N CD in front of others, inappropriate sexual behavior, etc.: (Attorney must sign above and type name below) ASSAULTIVE OR COMBATIVE BEHAVIOR: Throws objects, strikes or punches, makes dangerous maneuvers with Y N CD Wheelchair, etc.: DANGER TO SELF: Attorney(s) for Indicated by self-neglect or harm, suicidal thoughts or attempts, etc.: Y N CD OTHER IMPAIRMENTS IN THOUGHT, MOODS, BEHAVIOR: Please Describe: _____________________________________________________________________ Office and P.O. Address ___________________________________________________________________________________ INITIAL PERSONAL CARE PLAN - Page 3 of 5 2001 Guardianship Forms Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : ___________________________________________________________________________________ JUDICIAL SUBPOENA Plaintiff(s) -against1. II. CARE PLAN : : RESIDENCE: Address: : ________________________________________________________________________________ _ Defendant(s) : ...................................................... Plan for chore services provided in home (if necessary): ______________________________________________________________________________________ ______ ______________________________________________________________________________________ THE PEOPLE OF THE STATE OF NEW YORK ______________________________________________________________________________________ ______________________________________________________________________________________ TO ______________________________________________________________________________________ ________________________ GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court Plan located at County of for nursing services and other medical or personal care services provided in home, adult family in room home, or congregate care facility (if necessary): , on the day of , 20 , at o'clock in the noon, and at any recessed ______________________________________________________________________________________ or adjourned date, to testify and give evidence as a witness in this action on the part of the ______ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ liable to Your failure to comply with this subpoena is punishable as a contempt of court and will make you ______________________________________________________________________________________ the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a ________________________ result of your failure to comply. ______________________________________________________________________________________ ______ Witness, Honorable , one of the Justices Plan for other services, including, rehabilitative, educational, social, and recreational services: of the ______________________________________________________________________________________ Court in County, day of , 20 ______ ______________________________________________________________________________________ ______________________________________________________________________________________ (Attorney must sign above and type name below) ______________________________________________________________________________________ ______________________________________________________________________________________ ________________________ ______________________________________________________________________________________ Attorney(s) for ______ 2. TREATING PHYSICIAN: NAME ____________________________ __ ADDRESS PHONE/FAX NUMBER Office and P.O. Address ____________________________ ____________________________ __ __ INITIAL PERSONAL CARE PLAN - Page 4 of 5 2001 Guardianship Forms Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : ____________________________ __ ____________________________ -against__ ____________________________ : __ Plaintiff(s) ____________________________ : __ Index No. Calendar No. ____________________________ __ JUDICIAL SUBPOENA ____________________________ __ : 1. CURRENT MEDICATIONS: ______________________________________________________________________________________ : ______ ______________________________________________________________________________________ Defendant(s) : .______________________________________________________________________________________ ..................................................... ______________________________________________________________________________________ ______________________________________________________________________________________ ________________________ THE PEOPLE OF THE STATE OF NEW YORK 2. OTHER PROFESSIONALS ASSISTING INCAPACITATED PERSON: NAME ADDRESS PHONE/FAX NUMBER ____________________________ ____________________________ ____________________________ __ __ __ ____________________________ ____________________________ ____________________________ GREETINGS: __ __ __ ____________________________ ____________________________ ____________________________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before __ __ __ ____________________________ ____________________________ ____________________________ , the Honorable at the Court __ __ __ located at County of TO in room , on the day of , 20 , at o'clock in the noon, and at any recessed 1. OTHER SIGNIFICANT PERSONS: or adjourned date, to testify and give evidence as a witness in this action on the part of the NAME ADDRESS PHONE/FAX NUMBER ____________________________ ____________________________ ____________________________ __ __ __ ____________________________ ____________________________ ____________________________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to __ __ __ the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a ____________________________ ____________________________ ____________________________ result of your failure to comply. __ __ __ ____________________________ ____________________________ ____________________________ Witness, Honorable , __ __ __ one of the Justices of the ____________________________ day of ____________________________ ____________________________ Court in County, , 20 __ __ __ ____________________________ ____________________________ ____________________________ __ __ __ (Attorney must sign above and type name below) Attorney(s) for 1. PLAN FOR FINANCIAL MANAGEMENT: (i.e. person(s) responsible to receive income and pay monthly bills.) ______________________________________________________________________________________ ______ Office and P.O. Address ______________________________________________________________________________________ ______________________________________________________________________________________ INITIAL PERSONAL CARE PLAN - Page 5 of 5 2001 Guardianship Forms Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. ______________________________________________________________________________________ : ______________________________________________________________________________________ JUDICIAL SUBPOENA Plaintiff(s) ________________________ -against: ______________________________________________________________________________________ ______________________________________________________________________________________ : ____________ Dated this __________ day of ____________________, 20 : ______. Defendant(s) : ...................................................... _____________________________________________ THE PEOPLE OF THE STATE OF NEW YORK Guardian for __________________________________ TO GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address INITIAL PERSONAL CARE PLAN - Page 6 of 5 2001 Guardianship Forms Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com